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Nurse turnover is expensive. It affects the safety and effectiveness of service in Intensive Care Units. This study hypothesised that frequent night duty is a major factor influencing turnover. The results of the study supported the hypothesis and found that level of job satisfaction, career prospects and mobility all interact in a nurse's decision to leave Intensive Care. Suggestions aimed at improving retention of nurses are offered.
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Nicky Mathews, RN, Certified Midwife, Certified Mothercraft
Nurse, Intensive Care Certificate. Jackie Campbell. PN, Certified Midwife, Communicable
Diseases Certificate, Intensive Care Certificate. This study was undertaken as part of the Intensive Therapy Course, 1989-90 at St. Vincent's Hospital. |
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Recruitment and retention of sufficient numbers of registered nurses (RN) to work in Intensive Care Units (ICU) is a major challenge for nursing administrators. The cost of advertising, interviewing and orientating nursing staff who once employed may only stay a short while, is at least $950.00 per nurse.
A shortage of nurses negatively effects the safety and effectiveness of services provided in ICU. Payment for filling staffing gaps with overtime shifts or agency stall is expensive and the quality of stall is often inadequate.
Job satisfaction varies intensively with staff turnover. An improvement in one's degree of job satisfaction results in successful nurse retention and therefore a decrease in staff turnover.
In the past two years there has been a 43% annual turnover rate amongst the nursing staff in ITU. The purpose of this study was to find reasons why these nurses leave ICU and to propose suggestions, based on data received, which may resolve the problems arising. The hypothesis of the study is that frequent night duty would present as a major factor in results obtained.
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A review of the literature on the topic of nurse turnover with particular emphasis on Intensive Care reveals that some studies emphasise staff retention, rather than recruitment, as the issue that should be addressed when attempting to solve the nursing shortage, (Whaley, et al., 1989, and Neathawk, Dubuque and Kronk, 1988). The study of Magnet Hospitals by McClure et al (1983) identified variables which determined why some hospitals were not experiencing any difficulties in attracting and retaining staff.
A number of studies provide evidence of an association between job dissatisfaction and staff turnover (Whaley et al, 1989; Kosmoski and Calkin 1986; and Perry et al 1988). Bamber (1988) suggests that the level of job satisfaction, stress and mobility all interact in the decision to leave, while Price and Mueller (1981) claim that expressed intentions concerning future job participation is a better predictor of turnover than job satisfaction alone.
Gypicer and Maciace (1978) emphasised the role of the nursing unit manager as being responsible for turnover, claiming that a successful head nurse enjoys a decreased turnover and improved staff relations.
Coffey, Skipper and Jung (1988) in examining the influence of day, afternoon, night and rotating shifts on job performance and stress of nurses found that job performances and satisfaction was less on a rotating roster than on a fixed roster. Although there has been a move towards studies of nursing turnover, there is still a general absence of research that attempts to associate perceptions of night duty with job satisfaction and ultimately staff turnover. Jenkinson (1981) demonstrated that staff rotating on to night duty experienced more side effects eg lethargy, gastro-intestinal upsets, headaches, mood changes etc than did staff on permanent night shift.
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Frequent night duty is a major contributing factor when considering why there is a lack of job satisfaction and staff retention in the ICU at St Vincent's Hospital.
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The sample consisted of 30 nurses who chose to leave ICU within the eight month time frame (Sept 89 - April 90). Participation in the study was voluntary.
A questionnaire was administered to participants, attached as Appendix 1.
An attitude score aimed at measuring scores of an individual response on a given scale that has a certain value (Likert Scale) was used. The questionnaire, accompanied by a letter of explanation and a self addressed stamped envelope, was either given personally to the staff member upon leaving or mailed to those who had left within the given time frame. The questionnaires were completed anonymously and returned to the researchers. A total score was then obtained for each factor on the questionnaire by adding the numerical response on the Likert scale.Limitations of the Methodology
Due to the small sample size, although receiving consistent results, the sample may not be representative of the whole population of persons choosing to leave ITU. The small sample size may inhibit the power of our statistical analysis.When correlating results, problems arose in regards to specific factors;
With regards to the Likert scale it is apparent that it was misinterpreted on occasions. This vas exhibited by the answers given to question 17, in which respondents were given an opportunity to reinforce their views.
To eliminate these problems, a pilot study could have been implemented whereby problems such as those would have been identified. Time restrictions prevented this being done.
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Thirty questionnaires were distributed, twenty returned (return rate 66.6%) of whom thirteen were Registered Nurses and seven were Clinical Nurse Specialists. Responses to questions two, three and four are presented below. Figure 1 depicts factors found which influenced resignation, based on the Likert Scale.
Length of time as Registered Nurse:
Length of ICU nursing experience:
Length of time worked at SVH ICU:
Figure 1. Factors influencing resignation based on the Likert Scale
Career Opportunities Elsewhere
To leave ICU to further one's career was the third highest scoring factor in influencing nurse's decisions to leave. When comparing the nursing classifications, CNS staff allocated a significantly higher score to this factor than did RNs. This suggests that on the career ladder in ICU there is little opportunity for advancement other than gaining practical experience.
As mentioned previously the accuracy of the results of this questionnaire must be doubted as not all subjects drove to work. For those who did drive to work, it rated highly in influencing their decision to leave as car parking difficulties was perceived as an added stress to their working day.
Educational Resources and Educational Opportunities within ICU
This was one of the lowest rating factors in consideration. Many subjects commented on the excellent educational resources and facilities available in ICU.Frequent night duty was considered the highest scoring factor influencing nurse's decisions to leave by both CNS and RN staff.
CNS staff allocated a significantly higher score than did RNs. Comments given suggest that this is because the 'in charge' role on night duty is accompanied by more stress in that shift is often poorly staffed, with staff often caring for two patients and with inexperienced agency staff. Two weeks of night duty in six weeks was viewed by many as being far too frequent, often taking up to one to two weeks to adjust adequately back to day duty.
Research done on the effects of night duty shows that it not only affects one's psychosocial well-being by unsociable hours of work but it also has a negative physiological influence.
Fiedor and Keys (1987) identified five frequent problems associated with night duty. These were: disrupted sleep; disrupted eating patterns; lack of exercise; imbalance of work; social activities and psychological effects. Physiological effects include headaches, nausea, gastro-intestinal upsets, change in bowel habits, malaise and increased indulgence in smoking and sedative drugs. Changes even as extreme as menstrual cycle disturbances can be attributed to disturbances of one's 'biological clock' which once interfered with takes up to six weeks to return to normal (Fiedor et al. 1987. Lamberg 1984).
Psychological effects are immense; lack of participation in social activities leads to a feeling of isolation; for some nurses a good self image is hard to maintain due to chronic fatigue; anxiety results from going to work in the dark by oneself, often public transport is not safe at that hour and feeling of neglect arise from inadequate time spent with family and friends.
Soks, Doyle and Pigram (1989) identified night duty as a major stressor when researching stress in St. Vincent's ICU. Suggestions to overcome the unpopularity of night duty include:
This was the second highest scoring factor in our study. St Vincent's Hospital due to Its geographical location attracts many young single members of a transient population, many of whom are attracted by travelling.
To overcome this factor working conditions ie pay, flexible rosters etc would have to be good enough to entice the individual to stay longer than planned.
This received a significant score from both CNS and RN staff. Many comments made were directed at poor communication from senior staff with a general lack of understanding in regards to the competence of junior staff.
Because of the closed environment in which the ICU nurse works, strong personalities are often intensified. The nurse inexperienced in ICU often feels intimidated by his/her seniors.
Improved communication, feedback both positive and negative, increased socialising amongst the unit members and the creation of a more relaxed working environment were suggestions proposed to overcome this factor.
This received a considerable score particularly from RNs as opposed to CNS staff. Perhaps it is the nurse who has not yet gained confidence in his/her nursing skills in ICU who require more support from peers than does the CNS who has specialised training or years of experience.
Suggestions for improvement were once again directed at more socialising, a more relaxed atmosphere, more personalized introductions to new staff and more understanding given to new staff members in regards to their level of competence.
Participation In Decision Making
This rated number four in the factors included in the study. Many found that their care for a patient was somewhat incomplete when they had no influence in, or discussion on, decisions made.
While poor communication between nursing and medical staff was noted, the regimental use of protocols and policies preventing an individual care pattern was stressed.
Suggestions made to overcome this feeling of lack of participation in decision making were:
This factor was not rated as high as might be expected. The fact that CNS staff rated it higher than RN staff may once again be attributed to the stress of the 'incharge' role with often inadequate and inexperienced staffing levels.
New staff to the unit found that the adjustment period, ic the first three months were particularly stressful. Research done by Soks, Doyle and Pigram (1989) regarding stress in St Vincent's ICU found staff personality conflicts and shift scheduling to be the main stressors experienced by staff.
When correlating the results obtained it is apparent that the three most frequently occurring factors influencing nurses decision to leave ICU were:
The study's hypothesis is therefore supported. Availability of educational resources and flexibility of study leave were the lowest rating factors studied.
Poor communication within ICU was commented upon frequently as a factor contributing to stress in ICU, lack of participation in decision making, perceived attitudes of senior staff, peer support and the unfavourable aspects of the ICU physical environment. Gypicer and Maciace (1987) in a study on retention of nurses point out that sound communication keeps critical care staff together.
The results of the questionnaire show that 50% of staff were satisfied with their job upon resignation, 20% dissatisfied and 30% very dissatisfied. The 50% of satisfied staff were the ones who chose to resign because of career opportunities elsewhere and life events outside work eg travel. The remaining 50% of staff left ICU because of a general dissatisfaction with a variety of aspects of their job, specifically night duty.
Over 50% of the subjects stayed in ICU less than 12 months. This indicated that many of the staff were mobile and attracted by the availability of alternative employment.
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The results of this study reveal that further and more extensive studies need to be conducted. As mentioned earlier the small sample size was a strong limiting factor in this research.
To examine what influences a nurse to stay in his/her job as well as why staff leave has to be considered when proposing solutions for staff retention. To compare this study's results with those of other ICUs would be an interesting exercise, particularly to those who have permanent night duty staff.
To gain reliable information from staff leaving ICU it would be beneficial to have someone who is seen to be outside the main stream of nursing management to conduct exit interviews. The researchers feel the honest responses received were obtained as they were not perceived to be attached to hierarchy. Comments made in an exit interview would then be collated and presented to nursing management.
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While this study's hypothesis that frequent night duty is a major factor influencing a lack of job satisfaction in ICU at St Vincent's Hospital was supported by the results, the study found that there were many other contributing factors.
The decision to leave arises from a variety of complex factors of which a few have been isolated. Level of job satisfaction. career prospects and mobility all interact in the decision to leave.
A huge stress in ICU is work overload resulting from inadequate staffing. If adequate staffing is maintained nurses are able to take all other frustrations in their stride.
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Nursing staff turnover in ITU
Using the scale below, please indicate, numerically, how the following
factors influenced you in your decision to leave ITU:
1 - NO
2 - no
3 - ?
4 - yes
5 - YES
Adapted from Shelley, S. 1. (1984), Research Methods in Nursing and Health, Little, Brown and Co, Boston
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